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Background

Chronic venous insufficiency (CVI) is a leading cause of lower extremity venous ulcers, with prevalence increasing significantly with age. Standard management includes compression therapy, wound debridement, venoactive drugs, and diligent wound care. However, a subset of patients experience slow or absent healing despite optimal treatment, leading to prolonged morbidity and reduced quality of life.

When conventional approaches fail to achieve closure, clinicians sometimes explore adjunctive strategies. This article presents a clinical case in which hirudotherapy (medical leech therapy) was used as an adjunctive measure for a patient with a recalcitrant venous ulcer, resulting in significant improvement.

Clinical Case Presentation

A 67-year-old female with a long history of varicose veins and chronic venous insufficiency presented with a non-healing ulcer on the medial aspect of her left ankle. The ulcer had been present for 16 months despite consistent use of multilayer compression bandages, regular debridement, and advanced wound dressings. At initial assessment, the ulcer measured approximately 4.8 cm × 3.5 cm, with a pale, fibrinous base, moderate exudate, and surrounding skin exhibiting hyperpigmentation, induration, and mild edema.

Duplex ultrasound confirmed saphenous vein reflux and competent deep veins but with documented valvular insufficiency in the perforator system. Vascular surgery consultation did not identify an urgent need for venous intervention, and conservative management was continued.

Treatment and Follow-up

Given the lack of progress with standard care, after obtaining informed consent, the clinical team introduced adjunctive hirudotherapy. Two to three medical-grade leeches were applied to perilesional healthy skin in each session, repeated every two weeks for a total of five sessions. Compression therapy and wound care were maintained throughout.

Following the first session, the patient reported a noticeable reduction in local swelling and a sensation of “relief” in the affected limb. After five sessions, the ulcer base transitioned from pale to healthy granulation tissue, exudate decreased significantly, and perilesional induration softened. The ulcer area reduced by approximately 65%, and complete epithelialization was achieved within eight weeks post-treatment. No recurrence was observed during a three-month follow-up period.

Proposed Mechanisms of Action

The salivary secretion of the medicinal leech contains a complex mixture of bioactive substances that may address key pathological factors in venous ulceration:

• Anticoagulant effects: Hirudin directly inhibits thrombin, reducing microthrombosis and improving local microcirculation.

• Anti-inflammatory actions: Compounds such as eglin and anti-stasin help modulate inflammation and may reduce edema.

• Tissue permeability: Hyaluronidase and collagenase can break down fibrotic tissue and improve local tissue oxygenation.

• Local circulatory effects: Histamine-like substances and acetylcholine promote local vasodilation, potentially alleviating venous hypertension at the microvascular level.

While these mechanisms do not correct the underlying venous reflux, they may create a more favorable wound-healing environment by addressing microcirculatory compromise and inflammation.

Safety Considerations and Limitations

Hirudotherapy is not without risks, particularly when used outside of controlled clinical settings. Key considerations include:

• Infection: The leech gut harbors Aeromonas hydrophila and other bacteria; antibiotic prophylaxis or close monitoring is often recommended.

• Bleeding and anemia: Prolonged bleeding or repeated applications may lead to significant blood loss, requiring monitoring of hemoglobin levels.

• Allergic reactions: Local or systemic hypersensitivity to leech salivary proteins may occur.

• Lack of standardized protocols: There is no established consensus on optimal session frequency, leech count, or concomitant wound care regimens.

In this case, treatment was administered under clinical supervision with appropriate infection control measures and monitoring.

Discussion

This case illustrates that for a patient with a chronic venous ulcer refractory to standard therapy, the addition of hirudotherapy was associated with marked clinical improvement and eventual wound closure. While the evidence base for leech therapy in venous ulcers remains limited, the observed outcome aligns with the biological plausibility of its effects on microcirculation, inflammation, and tissue fibrosis.

Such cases highlight the need for well-designed studies to evaluate the potential role of hirudotherapy as an adjunctive treatment in patients with difficult-to-heal venous ulcers where standard options have been exhausted.

Conclusion

Hirudotherapy should not be viewed as a replacement for established treatments such as compression therapy or venous intervention. However, in selected patients with chronic venous ulcers that fail to respond to standard care, it may serve as a potential adjunctive approach when applied under appropriate clinical supervision. Self-application outside a medical setting carries significant risks and is strongly discouraged.

Keywords: hirudotherapy, chronic venous ulcer, venous insufficiency, wound healing, microcirculation

Reference (for professional context):
*Adapted from the clinical observation model presented in: Luke N.D., Henn C.H., Bansal M. Improving Symptoms of Peripheral Artery Disease With Hirudotherapy. Cureus, 2021. DOI: 10.7759/cureus.16270*